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Evidence-Based Clinical Practice Guidelines for OBSTETRICS AND GYNECOLOGY
1.
2. Evidence-Based
Clinical Practice Guidelines
For Staff of
Obstetrics & Gynecology Department
King Khalid University Hospital
2013
PART 1: Introduction
Instructor
Dr. Yasser Sami Amer, MBBCh, MSc
Pediatrician - HC Informatician
Member, G-I-N Adaptation Working Group/Steering Committee
CPGs General Coordinator, QMD, CPG Committee,
King Saud University Hospitals
KKUH/KAUH
4. Two Different Approaches to Evidence-Based
Practice (EBP)
Clinical Practice Guidelines (CPGs)
•“Top-down” approach
• Tell clinicians how to practice
• Favored by health care systems
Evidence-Based Medicine (EBM)
•“Bottom-up” approach
• Teach clinicians how to find answers
• Favored by medical educators
7. Definition: (old)
“Systematically developed statements to assist
practitioner and patient decisions about
appropriate health care for specific clinical
circumstances” (Institute of Medicine 1990).
Increasing international interest in the
development and implementation of CPGs.
Clinical Practice Guidelines (CPGs)
8. CPGs New Definition
CPGs are “Statements that include
Recommendations intended to optimize
patient care that are informed by a
Systematic Review of evidence and an
assessment of the benefits and harms of
alternative care options”.
Committee on Standards for Developing
Trustworthy CPGs (IOM-AHRQ)
9.
10. Rationale for CPGs
• Worldwide concerns about:-
▫ Unexplained variations in clinical practice
▫ Rising health care costs
▫ Exponential growth of information
• Aim of CPGs:-
▫ To facilitate more consistent, effective and
efficient practice and improve health
outcomes for patients
19. Clinical-Obstetrics Antenatal care & pregnancy 19
General 8
Intrapartum Care, Labour & birth 19
Models of care 4
Standards of maternity care 1
The Neonate 3
Clinical-
Gynecology
Cervical Screening & Cervical Cancer 4
Contraception 6
Gynecological Surgery/Procedures 7
Menopause 4
Menstrual Disorder 1
Reproductive Endocrinology 3
Termination of Pregnancy 2
24. Shaikh Bahamdan’s Research Chair for Evidence-
Based Health Care & Knowledge Translation
Member of G-I-N since Oct. 2009
Free access to International CPG Library of G-I-N
31. The Main CPGs Database websites we start searching:-
1- National Guidelines Clearinghouse
(NGC): www.guidelines.gov
2- Guidelines International Network (G-I-N) (International
Library): www.g-i-n.net
3- National Institute of Clinical and Health Excellence
(NICE): http://www.nice.org.uk/guidance/
4- Scottish Intercollegiate Guidelines Network
(SIGN): http://www.sign.ac.uk/guidelines/
5- DynaMed database: Evidence-based clinical
reference https://dynamed.ebscohost.com/
6- National Health and Medical Research Council - Australian
Government: http://www.nhmrc.gov.au/guidelines-
publications
7- Google/ Google Scholar: www.google.com
36. Adaptation of Clinical Practice Guidelines
The ADAPTE collaboration is an
international collaboration of CPG researchers, developers and
implementers. Their main aim is to develop and validate a
generic adaptation process that will foster valid and high-quality
adapted guidelines as well as the user’s sense of ownership of
the adapted guideline.
37. Guideline Adaptation
• Is the systematic approach to the endorsement and/or
modification of a guideline(s) produced in one cultural
and organizational setting for application in a different
context. Adaptation may be used as an alternative to
de novo guideline development, e.g., for customizing
(an) existing guideline(s) to suit the local context.
• http://www.adapte.org/
39. We identified 3 main ADAPTE steps:-
Adaptation Phase
Search & Selection of source CPGs
Health Questions (PIPOH)
AGREE II Instrument
Assess source CPGs quality
External Review
(Departmental Consensus)
40. We expect your invaluable input through assigning
The Obs. & Gyn. CPG Subcommittee/team members
representing each of your divisions (subspecialties):-
1 General Obs/Gyn
2 Oncology
3 Maternal Fetal Medicine
4 Assisted Reproduction
5 Uro-gynecology
41. CPG Scope: PIPOH Model
Patient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
= Health/ Clinical/ Key Questions
46. Considerations before a CPG
Assessment
• increase the reliability of the assessment
2 – 4 Appraisers
• in full and obtain all related information and
needed documents before undertaking the
AGREE II assessment ( to make a well
informed assessment)
Read CPG first
47. 23 Items in 6 Domains
USER’S MANUAL page 7
DOMAINS No. of Items
1 Scope & Purpose 3
2 Stakeholder Involvement 3
3 Rigour of Development 8
4 Clarity & Presentation 4
5 Applicability 3
6 Editorial Independence 2
48. 7. Systematic methods for E
search
8. Selection Criteria of E
9. Strengths & Limitations of E
10. Methods of Rs
11. Benefits , side effect and risks
in Rs
12. Evidence Links (Gs of Rs –
LoE)
13. External Review
14. Update Procedure
DOMAIN 3. RIGOUR OF DEVELOPMENT
Methods, literature search
strategy & appendices
+ inclusion/ exclusion criteria
+ Evidence tables, clinical
evidence, evidence description
(results), evidence
interpretation (discussion)
Methods, CPG Development
process
same sections
+ Rs, Key Evidence
+ acknowledgements
+ CPG update, date of CPG
50. CPGs: 1 (or 2) documents
FIRST (Clinicians’ Version)
• Accessible from ALL points-of-care
for the hospital staff:
• Details of evidence-based
recommendations for management
(with only references to the other
document)
51. SECOND:
(Methodologist’s Version) ;
• Accessible from Libraries
of e.g.
Department, College of
Medicine, CPG
Committee, QMD, Authors
hip group,…etc. (Reference for
Replication & Documentation)
• Detailed description of the
CPG Adaptation process
with ALL relevant data.
53. Dissemination of CPGs
• External Review
• Full CPGs documents published on websites
• Implementation tools will also be published:
examples for choice:-
1. Quick Reference Guide (Summary Key Rs)
2. Clinical Algorithms (decision tree)
3. Clinical pathways (Integrated care pathways)
4. Order Sets
5. Patient Information (Education Guide) Arabic
6. Clinical Audit Tool
7. CPOE (Computerized Physician Order Entrty) = e-
SIHI (New HIS)
8. ICD – 10 Codes
54. • If CPGs are to have a positive impact on
patient care outcomes they must be
implemented and incorporated into
everyday clinical practice
• The identification of any barriers to
implementation, and strategies for
overcoming them, will form an essential
part of discussions at CPGs
Subcommittee/ Adaptation Group
meetings
Implementing Guidelines